Lambeth / Southwark TIA Referral Form
Clinical Referral email: gst-tr.gsttstrokereferrals@nhs.net St
Thomas’
Clinical Fax Referral: 0203 2998504 King’s
Date / Method of Referral:
Date of referral __/__/____
Patient details
Name:
Address:
Date of birth: __ / __ / ____
Tel Home:
Mobile:
Tel:
Fax:
Hemiparesis / leg weakness
Loss of sensation
Loss of speech
Vertigo
Double vision
Loss of co-ordination
Present
Right
Left











Heart failure
Diabetes
AF
PVD
C = Clinical
Features
D = Duration
of Symptoms
D = Diabetes
History of Treatment / Other Relevant Information
/

Smokes


Obesity


 Previous Stroke/ TIA

Migrane


 Other

True aspirin intolerance: Yes  No 
ABCD2 Score
A = Age
B = BP
Other 
Blood Pressure
Date of symptoms:
Duration of symptoms to complete resolution:
Past medical history / Vascular risk factors
Hypertension
 Hyperlipidaemia
Isch. Heart Disease

Patient GP Details
Name:
Address:
Clinical features
Hemiparesis /arm weakness
GP
Score
>60
>140 Systolic and/or 90
Diastolic
Unilateral Weakness
Speech disturbance w/o
weakness
Other
>60 minutes
10 – 59 Minutes
< 10 Minutes
Diabetes
Current Medications
*Give patient stat dose 300mg aspirin daily, unless contra
indicated (e.g. on warfarin) and provided all symptoms have
resolved
Patient
Score
Patient Advice
1
1
Tell the Patient:
2
1
-He or she should not drive until he or she has been
assessed at hospital or clinic
0
2
1
0
1
-If there was a witness to the event, that person
should accompany the patient to the hospital or
clinic
2
-If the patient experiences any further event he or
she should go immediately to A&E
Total ABCD Score
Referral Information
Guy’s and St Thomas’ NHS Foundation Trust
King’s College Hospital NHS Foundation Trust
Send to St Thomas’ A&E if any of the below apply:

ABCD2 Score ≥4

≥ 1 TIA in a week

On Warfarin or in AF (Atrial Fibrillation)

< 50 yrs, with prominent neck pain / headache
Send to King’s A&E if any of the below apply:

ABCD2 Score ≥4

≥ 1 TIA in a week

On Warfarin or in AF (Atrial Fibrillation)

< 50 yrs, with prominent neck pain / headache
Refer to GSTT TIA Clinic via email if ABCD2<4 and TIA
suspected (Monday P.M. & Thursday A.M.)
If no to all of the above, call TIA Nurse/ stroke on call
registrar for next day admission to PIU (Patient
Investigation Unit) and fax referral form.
Team Secretary (appointments, chase referral) 0207 1882515
TIA Referral email: gst-tr.gsttstrokereferrals@nhs.net
Stroke Team via St Thomas’ Switchboard 0207 1887188
(bleep 1765) Prof Rudd, Dr Bhalla, Dr Birns.
Refer to King’s TIA Clinic via fax, if symptoms occurred >
72 hours earlier (Tuesday A.M.)
TIA Nurse: 07528977503
TIA Referral Fax: 020 3299 8504
Stroke Registrar via King’s Switchboard: 020 3299 9000
IF SYMPTOMS PERSIST THROUGH CLINICAL ASSESSMENT THEN BLUE LIGHT TO NEAREST A & E.